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 Sample Submission Form 

AC Diagnostics Testing Services

Sample Submitted by:
Name:________________________________ Company:__________________________________
Address:__________________________________________________________________________
City:_______________________ State:_______ Zip:___________ Country: __________________
Phone:______________________ Fax:_____________________ Email:______________________

Sample identification (Sample type and Numbers):

Crop Screen (Contains tests for frequently encountered viral pathogens of a particular crop. Recommended if you are not sure which pathogen to test for) : _________________________

Special Test(s) Ordered (Please contact us for tests suitable for your crop):_____________ _________________________________________________________________

Send invoice to:    Check here if same as above [   ]
Company:____________________________________________ Attn:_______________________
Address:_______________________________ City:____________ State:______ Zip:__________

Method of payment:
[   ] Bill to purchase order number:_______________________________,   [    ] Check Enclosed
[   ] American Express   [   ] Visa   [   ] Mastercard    Account Number:____________________ 
    Exp. date:_______________  Cardholder's Signature:________________________________

Note:  
· Please submit samples via overnight courier (Fed Ex, DHL, UPS, Airborn, etc.)
· For detailed information, please see Sampling and Submitting in this Web Site.